Gestational gigantomastia

Abstract

A case of massive hypertrophy of the breasts in pregnancy was seen in our institution, which is a tertiary referral centre for the United Arab Emirates region with a delivery rate of 7000/year. It is a very rare condition (1 in 100000) and the only case seen in our hospital over the past 20 years. No similar case has been reported from the United Arab Emirates or Gulf regions, to our knowledge. The patient presented at a gestational age of 18 weeks on account of progressive swelling of the breasts which started at 14 weeks’ gestation. In pregnancy she was managed conservatively with analgesics, bromocriptine and breast support. She had bilateral reduction mammoplasty 1 year after delivery. The outcome was satisfactory, and the patient was pleased with the cosmetic result.

BACKGROUND

Massive hypertrophy of the breasts in pregnancy is a very rare condition (1 in 100 000) of undetermined aetiology.¹ Management in pregnancy is controversial and challenging. It accounts for physical and psychological maternal morbidity. Rapid enlargement of breasts causes pain, ulceration, necrosis, infection and haemorrhage.² Management in pregnancy includes adequate breast support and bromocriptine. First trimester pregnancy termination and urgent mastectomy may be needed if fatal complications occur.¹ Postpartum lactation suppression³ and reduction mammoplasty after complete involution gives optimum results. We report a case of gestational gigantomastia, the only one seen in our institution over the last 20 years, to highlight the management challenges.

We decided to write the report so that practising gynaecologists and obstetricians become more confident in managing such a rare condition. A favourable outcome can be achieved with prompt recognition of the condition, avoiding unnecessary investigations and conservative approach in selected cases.

CASE PRESENTATION

A woman aged 32 years presented to our antenatal clinic in her third pregnancy at 18 weeks of gestation with rapid enlargement of both breasts since the beginning of conception. There was past history of multiple breast lumps for which she underwent lumpectomy four times and this was diagnosed as fibroadenosis on each occasion. In her first pregnancy, there was increase in brassiere size from 32B to 36B but otherwise it was an uneventful pregnancy, term delivery of a healthy male baby and lactated for 11 months. There was no significant change in breast size during her second pregnancy and she delivered a term female baby.

In the index pregnancy, she noticed a rapid increase in her breast size at 14 weeks of gestation for which she was prescribed bromocriptine by a private practitioner. At 18 weeks she had to use a brassiere of size 38B. She had pain and redness in the skin over the breasts and bromocriptine was continued at 2.5 mg three times daily.

INVESTIGATIONS

Histopathology of excised breast tissue at reduction mammoplasty (1 year after delivery) showed areas of fibroadenosis and chronic inflammatory changes.

DIFFERENTIAL DIAGNOSIS

Benign breast hypertrophy and breast neoplasia.

TREATMENT

At 25 weeks’ gestation, she needed admission to hospital because of difficulty in walking and breathing. A brassiere size of 46B could not support her breasts. Redness and oedema of the skin was increasing, but without ulceration or necrosis (fig. 1).

Figure 1.

Appearance of breasts at 25 weeks of gestation.

She was given breast binders and bromocriptine continued. By 28 weeks, she was so uncomfortable that she even requested termination of the pregnancy. She needed strong analgesics for pain and greater psychological support. The breast circumference was 70 cm at a point midway between nipple and chest wall. Tender axillary nodes were noticed and surgical opinion taken.

Biopsy was not indicated and conservative management was advised. Her weight increased from 54 kg at booking to 72 kg by 30 weeks, mostly due to massive breast enlargement as she had no oedema or excess fat deposition in her body. Obstetric ultrasound revealed a normally grown foetus.

She went into spontaneous preterm labour at 33 weeks and delivered a 2.1 kg female baby.

Postnatally, bromocriptine was continued and breastfeeding was avoided.

OUTCOME AND FOLLOW-UP

Breast size and redness slightly reduced (fig 2). She did not want further pregnancies and opted for an intrauterine contraceptive device. There was gradual involution of the breasts, and at 10 months postpartum, a 38B size brassiere was needed. She underwent bilateral reduction mammoplasty by a plastic surgeon 1 year after delivery. Her brassiere size reduced to 34B (fig 3). She was asymptomatic and pleased with the cosmetic result at the next follow-up visit 6 weeks later.

Figure 2.

Appearance of breasts postpartum.

Figure 3.

Appearance of breasts after reduction mammoplasty.

Histopathology showed areas of fibroadenosis and chronic inflammatory changes.

DISCUSSION

Massive hypertrophy of the breast seems to occur only in adolescence and pregnancy. It is a very rare disorder with less than 125 cases reported in the literature.¹ The aetiology remains unknown, but since the condition occurs within days of conception, it may represent hypersensitivity of breast tissue to chorionic gonadotrophin hormone. It can occur in any pregnancy, unilaterally or bilaterally, with capacity to recur in all subsequent pregnancies.² Gravidic macromastia is a psychologically and physically disabling condition. Adequate breast support and prolonged bromocriptine therapy is the most consistent conservative therapy. Termination of pregnancy in first trimester may be needed if the skin overlying the hypertrophied breast gets severely ulcerated and necrosed. Rarely bilateral mastectomy may be needed but there is danger of massive haemorrhage.¹

Infection and malignancy should be excluded in these cases. Histology of affected breasts reveals glandular hyperplasia and overgrowth of connective tissue with absence of adipose tissue. Rarely fibrocystic disease or cancer may be associated findings. The decision to perform a biopsy is difficult as it can cause ulceration and haemorrhage. Suppression of lactation in the puerperium is mandatory with bromocriptine, as further engorgement may precipitate infection and necrosis.³

Involution after delivery is unpredictable. Reduction mammoplasty after involution is complete gives the best results.³ If the patient is planning future pregnancies or has coincident disease in breasts such as fibroadenosis, then total subcutaneous mastectomy with immediate implantation of nipple–areola complex is recommended.³

LEARNING POINTS

• Hypertrophy of breasts in pregnancy is a psychologically and physically disabling condition of a severe degree.

• Conservative management (breast support and prolonged bromocriptine therapy) is advisable in pregnancy in selected cases.

• Urgent surgical intervention is needed if fatal complications occur at any stage.

• Improvement after delivery is likely but postpartum aggravation of the condition is possible and hence lactation suppression is essential.

• Postpartum reduction mammoplasty, if the woman is planning future pregnancies, is advised, otherwise total mastectomy is the optimum surgical treatment with the lowest recurrence risk.